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Update on fatal crash of Beaver Seaplane

Jan. 29, 2010, Gatineau, Que. – The Transportation Safety Board of Canada (TSB) recently announced that several examinations of the aircraft are complete and that the investigation is progressing quickly.


January 29, 2010  By Administrator

Jan. 29, 2010 – The Transportation Safety Board of Canada (TSB) announced today that
several examinations of the aircraft are complete and that the
investigation is progressing quickly. In its investigation of the
November 29, 2009 seaplane crash, the TSB is reviewing not only the circumstances of this accident, but prior accidents to see where common safety deficiencies exist.

The TSB
team is now engaged in the analysis of all data gathered to date and is
working towards drafting its report for the next phase of the
investigation – internal review.

Work Completed to Date

The team has done a significant amount of work. It oversaw the
recovery of the aircraft from Lyall Harbour and its transport to the TSB
facility in Richmond, British Columbia. Thorough examinations of the
aircraft have been completed. Interviews with the pilot and surviving
passenger were carried out and statements from witnesses in the area
have been reviewed.

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Factual Information

The Seair de Havilland Beaver was departing Lyall Harbour, Saturna
Island, at about 1600 Pacific standard time, on a flight to Vancouver
International Airport, British Columbia. There were eight persons on
board—one pilot and seven passengers including an infant. The winds
were generally from the southeast, but gusting and variable. In open
areas, the wind was blowing to about 30  knots. After an attempt to
take off to the northwest, the pilot turned the aircraft southeast and
then took off into the harbour. Once airborne, the aircraft remained
below the surrounding terrain and during a turn to the left, it
descended and collided with the water near the north shore of the
harbour. An immediate emergency response was initiated, but the
aircraft sank quickly and was completely below the water surface before
first responders arrived. Responders rescued the pilot and an adult
passenger from the surface of the water. Exhaustive searches found no
other survivors. Later, Canadian Coast Guard divers retrieved six
bodies from the wreckage resting on the bottom of the harbour, in
approximately 14 m of water.

The wreckage was retrieved from the bottom of the bay and
transported to a facility in Richmond. Several examinations revealed
damage consistent with a hard impact at a flat attitude with high
engine power. The left cabin door, which is normally used for embarking
and disembarking passengers, was jammed shut from the airframe's
deformation on impact. The right cockpit door was found jammed shut by
the divers, but investigators were able to force it open after the
wreckage was retrieved. The right cabin door and the left cockpit door
appear to have popped open. The two survivors were seated next to those
two open doors.

Neither of the survivors donned lifejackets and none of the
available lifejackets had been removed from the aircraft. Five were
still in their storage pouches. Five of the passengers remaining in the
aircraft were free from their seatbelts.

The aircraft appears to have been in good serviceable condition
before impact. Records indicate that there were no outstanding
maintenance deficiencies, and that all of its modifications were
approved.

This accident echoes the findings from previous TSB investigations including:

  • occupants of submerged seaplanes who survive the accident continue to be at risk of drowning inside the aircraft;
  • occupants who escape a submerged seaplane may drown without floatation assistance; and
  • seaplanes may not be optimally designed to allow easy occupant escape while under water.

Investigation Activities in Progress

Flight tests on a similar aircraft are planned to acquire
performance numbers in different configurations, and those will be
compared.

Wind conditions at the time of the accident are being analysed to determine if they may have been a factor in the accident.

At the same time, investigators are researching other floatplane
accidents in order to examine the recurring risks and what can and
should be done to mitigate those risks. We are looking at our past
safety communications and at the responses from the regulator and
industry to resolve the concerns raised by the TSB. While the Board is not making new recommendations at this time, this investigation has focused the TSB's
attention on a number of issues regarding jettisonable or push-out
emergency exits on seaplanes, underwater egress training for air crew,
pilot training for flight in mountainous areas, aircraft handling
characteristics, and the wearing of personal floatation devices.

Cooperation with Others

The survivors and the families and loved ones of those lost in this accident are first in the thoughts of the TSB
investigation team. We keep in contact with those involved and hope
that our efforts will help everyone understand what happened, why it
happened and what needs to be done in the future to prevent its
recurrence.

Transport Canada is kept up to date through its Minister's Observer
to allow for immediate action should critical safety issues be
identified.

The Investigator-in-Charge is working closely with the British
Columbia coroner to identify the risks to persons and mitigation
strategies.

Next Steps in the Investigation Process

Once all the available data are analysed, an initial draft
investigation report will be completed, the Board will review it and an
approved confidential draft report will be sent to persons and
corporations whose interests may be affected by the report and who are
most qualified to comment on its accuracy. They then have the
opportunity to dispute, correct or contradict information that they
believe is incorrect or unfairly prejudicial to their interests.

This process is intended to ensure procedural fairness and the
accuracy of the Board's final report. The Board considers all
representations (comments) and will amend the report if required. Once
the Board approves the final report, it is prepared for release to the
public.

As the investigation continues, should the TSB
identify risks requiring immediate action, it will issue safety
communications advising industry and regulators what needs to be done
to improve safety in this important segment of the aviation industry.

The TSB
is an independent agency that investigates marine, pipeline, railway
and aviation transportation occurrences. Its sole aim is the
advancement of transportation safety. It is not the function of the
Board to assign fault or determine civil or criminal liability.

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